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Kliiniline küsimus nr 9
Kas patsiendi postoperatiivse ägeda valu ravis mõjutab ravimite1 manustamise viis i/v
vs i/m vs enteraalne valuravi tulemust?
paratsetamool, NSAIDid, opiaadid
Tulemusnäitajad: valu tugevus, valu vähenemine, aeg valuvaigistava toime
saabumiseni, lisavaluvaigisti vajadus, aeg esimese lisavaluvaigisti vajaduseni,
toime kestus,
valuvaigistitest tingitud kõrvaltoimed, rehospitaliseerimine valu tõttu, patsiendi
(eestkostja) rahulolu valuraviga, meetodi ohutus
Manustamisviiside otseseid omavahelisi võrdlusi on vähe.
nsNSAID ja koksiibid: parenteraalsel ja enetraalsel manustamisel ei ole vahet
efektiivsuses ja kõrvaltoimete esinemissageduses (Level I soovitus), kuid on
oluline hinnavahe.
Paratsetamool: p/o manustamisel vahetus postop perioodis ja rektaalsel
manustamisel üldiselt on biosaadavus väga varieeruv ning osadel patsientidel võib
seetõttu olla kontsentratsioon vereplasmas subterapeutiline.
Opioidid: i/v püsiinfusiooniga suurem hingamisdepressiooni oht kui teiste
manustamisviisidega (Level IV soovitus). Opioidide i/m vajadusel manustamisel on
valuravi kvaliteet halvem kui i/v PCA-ga (Level I soovitus). Võrdluses i/m ja s/c on
s/c manustamine patsientide poolt eelistatud, muid erinevusi ei ole.
i/m manustamine: ei ole soovitatav (Level I soovitus)
1.“Behandlung acuter perioperativer und postraumatischer Schmertzen”
2009 (DE-07)
The grading system of the guideline
Degree of
Level of
Systematic review of controlled randomized clinical trials
Controlled randomized clinical trials with a strict confidence interval
“All or nothing” therapeutic results
Systematic review of cohort studies
Cohort studies (including lesser quality randomized clinical trials)
Observation of therapeutic results (outcomes research).
Systematic review of case-control studies
Case-control study
Case report (including cohort or case-control of poor quality)
Specialists’ opinions lacking critical evaluation or based on basic
matters (physiological study or study with animals)
I/m administration of analgesics is not recommended. GoR: A
I/m injections are painful (LoE: 4) (Cupitt und Kasipandian, 2004).
I/m injections – risk of nerve damage, risk of haematomas (LoE: 4) (Greenblatt
und Koch-Weser, 1976; Muller-Vahl, 1983; Tong und Haig, 2000).
2. Acute Pain Management: Scientific Evidence 2010 (AU10)
Administration of systemic analgesic drugs (opioids, nsNSAIDs and coxibs) - direct
comparisons between oral and other routes of administration are limited.
Key messages:
NSAIDs (nsNSAIDs and coxibs) given parenterally or rectally are not more
effective and do not result in fewer side-effects than the same drugs given
orally (U) (Level I (Cochrane review).
Early postoperative p/o paracetamol results in highly variable plasma
concentrations that may remain subtherapeutic in some patients (N) (Level II)
Rectal administration of single doses of paracetamol results in highly variable
plasma concentrations that often remains subtherapeutic (N) (Level II)
Intermittent s/c morphine injections are as effective as i/m injections and have
better patient acceptance (U) (Level II)
Continous i/v infusions of opioids in the general ward setting is associated
with an increased risk of respiratory depression compared with other methods
of parenteral opioid administration (U) (Level IV)
Conclusions based on clinical experience and expert opinion:
Other than in the treatment of severe acute pain, and providing there are no
contraindications to its use, the oral route is the route of choice for the
administration of most analgesic drugs (U).
Controlled-release opioid preparations should only be given at set time
intervals (U).
Immediate-release opioids should be used for breakthrough pain and for
titration of controlled-release opioids (U).
The use of controlled-release opioid preparations as the sole agents for the
early management of acute pain is discouraged because of difficulties in shortterm dose adjustments needed for titration (U).
 Morphine liquid 20mg every 4h provides better pain relief after hip surgery than
im morphine 5-10mg prn (McCormack et al 1993 Level II)
 Incidence of resp. depression from 0.8 (0.2-2.5)% to 37 (22.6-45.9)% using
respiratory rate and oxygen saturation, respectively, as an indicators. (review by
Cashman and Dolin 2004) Level IV
 Quality of pain relief was less with intermittent im regimes than with iv PCA
(Hudcova et al 2005) Level I
 In children, there was no difference in rate of onset, analgesic effect and side
effects when s/c morphine compared with i/m, significantly higher patient
preference for the s/c route (Cooper et al 1996 Level II; Lamacraft et al. 1997
Level IV).
 i/m and s/c morphine after Cesarean section -no significant difference in side
effects, patient satisfaction or pain relief at rest, but lower pain scores after s/c
administration at 12, 16, 20h after surgery (Safavi and Honarmand 2007 Level
 Comparison of same morphine dose single s/c or i/v inj - i/v resulted in more rapid
onset of analgesia (5 min i/v; 20 min s/c) and better pain relief between 5 min and
25 min after injection, but also led to higher sedation scores up to 30 min after
injection and higher PCO2 levels (Tveita et al. 2008 Level II).
 Intermittent s/c morphine inj are as effective as i/m and have better patient
acceptance (Level II)
 i/v tramadol was more effective than same dose given p/o after dental surgery,
difference in bioavailability of single dose of tramadol may be up to 30% (Ong et
al. 2005; Level II)
 Large i/v doses of tramadol can result in a high incidence of emetic symptoms
(Pang et al 2000, Level II).
 Compared with PCA, continous iv opioid infusions in a general ward setting
resulted in a 5-fold increase in the incidence of respiratory depression (Schug and
Torrie, 1993, Level IV).
 In cancer pain patients – no difference in pain relief or ADRs between po and
rectal tramadol (Mercadante et al 2005, Level II)
 No good evidence that nsNSAIDs given parenterally or rectally are more effective
or result in fewer side effects than the same drugs given orally for the treatment of
postop pain (Tramer et al. 1998 Level I).
 Limited number of nsNSAIDs/ coxibs available for i/m inj. Ketorolac and
parecoxib i/m are effective analgesic agents (Smith et al 2000 Level I; Lloyd et al
2009 Level I).
 In single doses as the sole analgesic agent, parecoxib iv 20 to 40mg has shown to
be effective (Lloyd et al 2009, Level I)
 In most cases the route of administration does not seem to alter efficacy. Iv
nsNSAIds and coxibs are more expensive although their efficacy and likehood of
side.effects is similar (Tramer et al. 1998, Level I)
 Comparison of rectal diclofenac and iv parecoxib showed no difference in pain
relief, side effects or rescue analgesic requirements (Ng et al. 2008; Level II).
 Efficacy and times to onset of analgesia were similar with iv and im parecoxib
(Daniels et al, 2001, Level II)
 No advantage in using nsNSAID if the oral route is available (Tramer et al. 1998,
Level I)
 Oral bioavalialbility is good (63-89% Oscier and Milner 2009), but early postop
oral administration can result in highly variable plasma concentrations and may be
subtherapeutic (Holmer and Pettersson et al. 2004, Level II).
 In the same doses p/o paracetamol was less effective and of slower onset than i/v,
but more effective and faster onset than per/rect.
 Paracetamol effervescent tablets were absorbed significantly faster than ordinary
paracetamol (Rygnestad et al. 2000, Level II).
 I/v – faster onset than same dose given orally (Moller, Sindet-Pedersen et al 005,
Level II), but more expensive.
 Due to the good bioavailability and tolerability of p/o paracetamol, the use if iv
form should be limited to clinical circumstances where enteral route is not
 Paracetamol is effective when given p/rect (Romsing et al. 2002, Level I), altough
rectal absorption of paracetamol is slower and less predictable than p/o
(bioavailability 24-98%, Oscier and Milner 2009).
 Less effective when same dose administered p/o (Anderson et al 1996, Level II,
Anderson et al 1999, Level IV)
Doses of 1g per/rect after cardiac surgery (Holmer Pettersson et al 2006 Level II)
and hysterectomy (Kvalsvik et al 2003 Level II) as well as 2g rectally after
laparoscopic gynecological surgery (Hahn, Morgensen et al. 2000 Level II) also
resulted in subtherapeutic blood levels. The levels may increase to within
therapeutic range after repeated administration (Holmer Petersson et al 2006
Level II).
When available, the oral route is preferable.
Süstemaatilised ülevaated ja meta-analüüsid
Kokkuvõte: Otsingu tulemusena leiti üks meta-analüüs, kus võrreldakse
ennetavaks või postoperatiivseks valuraviks ühekordse annusena manustatud iv
paratsetamooli või per os paracetamooli. Meta-analüüsi tulemusena selgus, et
statistilist erinevust kahe manustamise viisi vahel ei ole või oli see kliiniliselt
McNicoll, E.D. et al (2011) „Single-dose intravenous paracetamol or
propacetamol for prevention or treatment of postoperative pain: a systematic
review and meta-analysis“ British Journal of Anaesthesia 106 (6): 764–75
Summary. Paracetamol is the most commonly prescribed analgesic for the treatment
of acute pain. The efficacy and safety of i.v. formulations of paracetamol is unclear.
We performed a systematic search (multiple databases, bibliographies, any language,
to May 2010) for single-dose, randomized, controlled clinical trials of propacetamol
or i.v. paracetamol for acute postoperative pain in adults or children. Thirty-six
studies involving 3896 patients were included. For the primary outcome, 37% of
patients (240/367) receiving propacetamol or i.v. paracetamol experienced at least
50% pain relief over 4 h compared with 16% (68/527) receiving placebo (number
needed to treat¼4.0; 95% confidence interval, 3.5–4.8). The proportion of patients in
propacetamol or i.v. paracetamol groups experiencing at least 50% pain relief
diminished over 6 h. Patients receiving propacetamol or paracetamol required 30%
less opioid over 4 h and 16% less opioid over 6 h than those receiving placebo.
However, this did not translate to a reduction in opioid-induced adverse events (AEs).
Similar comparisons between propacetamol or i.v. paracetamol and active
comparators were either not statistically significant, not clinically significant, or both.
AEs occurred at similar rates with propacetamol or i.v. paracetamol and placebo.
However, pain on infusion occurred more frequently in those receiving propacetamol
compared with placebo (23% vs 1%). A single dose of either propacetamol or i.v.
paracetamol provides around 4 h of effective analgesia for about 37% of patients with
acute postoperative pain. Both formulations are associated with few AEs, although
patients receiving propacetamol have a higher incidence of pain on infusion.
Paratsetamool Otsingu tulemusena leiti kaks RCT-d, mis ei anna täpset vastust
uuringuküsimusele. Uuringud käsitlevad pre- või intraoperatiivses perioodis
manustatud paratsetamooli iv või po, kuid mõõdavad postoperatiivse valu
tugevust. Uuringu tulemusest selgus, ennetava analgeesiana paratsetamooli
manustamse viis ei mõjuta postoperatiivse valu tugevust. (Fenlon et al 2013, Brett
et al 2012 ).
nsNSAID Otsingu tulemusena ei leitud ühtegi RTC-d, mis vastaks konkreetselt
uuringuküsimusele. Leidus uuringuid, mis käsitlevad valuvaigistitest tingitud
kõrvaltoimeid (primaarne ja sekundaarne veritsus ja PONV).
Koksiibid Otsingu tulemusena ei leitud ühtegi RTC-d, mis vastaks konkreetselt
uuringuküsimusele. Leidus uuringuid, mis käsitlevad valuvaigistitest tingitud
kõrvaltoimeid (veritsus ja PONV).
Opioidid: Leidus ainult 1 värske (viimase 10 a jooksul avaldatud) RCT, mis vastas
uuringuküsimusele. Võrreldi 10mg i/v ja 10mg i/m morfiini. i/v – oluliselt kiirem
analgeetilise toime algus kui i/m (5 vs 20 min) ja suurem valu vähenemine samas
ka veidi suurem paCO2 tõus ja tugevam sedatiivne toime (Tveita et al. 2008)
PubMed search for Paracetamol:
Filters activated: Meta-Analysis, Randomized Controlled Trial, Systematic Reviews,
published in the last 5 years, Humans.
MeSh terms used:
"route of administration"
"postoperative pain"
“adverse effects"
"pain/prevention and control"
"treatment outcome"
1. "paracetamol"[All Fields] AND "acetaminophen"[All Fields] AND ((MetaAnalysis[ptyp] OR Randomized Controlled Trial[ptyp] OR systematic[sb]) AND
"2009/10/08"[PDat] : "2014/10/06"[PDat] AND "humans"[MeSH Terms]) Results:
2. "paracetamol"[All Fields] AND "acetaminophen"[All Fields] AND ((MetaAnalysis[ptyp] OR Randomized Controlled Trial[ptyp] OR systematic[sb]) AND
"2009/10/08"[PDat] : "2014/10/06"[PDat] AND "humans"[MeSH Terms]) Results:
425 (filter 10 years)
3. "paracetamol administration"[All Fields] AND ((Meta-Analysis[ptyp] OR
Randomized Controlled Trial[ptyp] OR systematic[sb]) AND "2009/10/08"[PDat] :
"2014/10/06"[PDat] AND "humans"[MeSH Terms]) Results: 15
Fenlon, S. et al (2013) „Oral vs intravenous paracetamol for lower third
molar extractions under general anaesthesia: is oral administration
inferior?“ British Journal of Anaesthesia 110 (3): 432–7
Background. Paracetamol formulations provide effective analgesia after surgery
[Duggan ST, Scott LJ. Intravenous paracetamol (acetominophen). Drugs 2009; 69:
101–13; Toms L, McQuay HJ, Derry S, Moore RA. Single dose oral paracetamol
(acetaminophen) forpostoperative pain in adults. Cochrane Database Syst Rev 2008:
CD004602]. I.V. paracetamol is superior to oral for pain rescue (Jarde O, Boccard E.
Parenteral versus oral route increases paracetamol efficacy. Clin Drug Invest 1997;
14: 474–81). By randomized, double-blinded trial, we aimed to determine whether
preoperative oral paracetamol provides inferior postoperative analgesia to
preoperative i.v. paracetamol.
Methods. One hundred and thirty participants received either oral paracetamol and
i.v. placebo (Group OP), or oral placebo and i.v. paracetamol (PerfalganTM) (Group
IP). Oral preparations were given at least 45 min before surgery; i.v. preparations
after induction of anaesthesia. Pain was assessed by a 100 mm visual analogue scale
(VAS) 1 h from the end of surgery. Rescue analgesia was given on request.
Results. A total of 128 patients completed the study. There were no significant
differences in baseline characteristics or intraoperative variables between the groups.
The study was designed to reveal whether OP is inferior to IP, with an inferiority
margin of 20%. The number of patients reporting satisfactory analgesia at 1 h with
VAS ≤30 mm were 15 (OP) and 17 (IP), respectively. The secondary outcome
measure of the mean (standard deviation) VAS (mm) for the whole of each group was
52 (22) for OP and 47 (22) for IP. Analysis of confidence intervals indicates that oral
paracetamol is not inferior to i.v. paracetamol. The median survival (90% CI) to
rescue analgesia request was 54.3 (51.2– 57.4) min in Group OP and 57.3 (55.4–59.2)
min in Group IP; there was no significant difference in this measure.
Conclusions. In this study of lower third molar extraction, oral paracetamol is not
inferior to i.v. for postoperative analgesia.
Brett, C. N., S. G. Barnett, and J. Pearson. "Postoperative plasma paracetamol
levels following oral or intravenous paracetamol administration: a double-blind
randomised controlled trial." Anaesthesia and intensive care 40.1 (2012): 166-171.
Aim: double-blind RCT, which method of administration achieves therapeutic plasma
levels most effectively in the early postoperative period.
Methods: 30 patients undergoing day case arthroscopy of the knee were randomised
to receive either 1g oral paracetamol 30 to 60 min preoperatively (20 patients) or 1g
i/v paracetamol intraoperatively (10 patients). Plasma paracetamol levels were
measured 30 min after arrival in the recovery room. Secondary outcomes included
postop pain scores, rescue analgesia requirements and duration of stay in the recovery
Results: All patients receiving the i/v preparation had plasma levels above the
analgesic level compared to less than half (7/20) in the oral group. Mean
plasma paracetamol levels were 88.6µmol/l for the i/v group and 53.2µmol/l for the
oral group (P=0.0005). There were trends towards reduced rescue analgesia and
duration of stay in the recovery room for the intravenous group although not reaching
statistical significance. There was no difference in pain scores between groups.
Conclusion: Intraoperative administration of 1g of i/v paracetamol more reliably
achieved effective paracetamol levels in the early postoperative period compared to
an equal dose given orally preoperatively. Only a minority of patients receiving the 1g
oral dose preoperatively had plasma levels in the therapeutic analgesic range.
PubMed search for nsNSAIDS/coxibs:
Filters activated: Randomized Controlled Trial, published in the last 5 years,
MeSh terms used:
"route of administration"
"postoperative pain"
"morphine/adverse effects"
"pain/prevention and control"
"respiration/drug effects"
"nausea/drug therapy"
"treatment outcome"
PubMed search for OPIOIDS:
Filters activated: Randomized Controlled Trial, published in the last 5 years,
MeSh terms used:
"opioid administration"
"route of administration"
"postoperative pain"
"morphine/adverse effects"
"pain/prevention and control"
"respiration/drug effects"
"nausea/drug therapy"
"treatment outcome"
Tveita, T., et al. "A controlled comparison between single doses of intravenous
and intramuscular morphine with respect to analgesic effects and patient
safety." Acta anaesthesiologica Scandinavica 52.7 (2008): 920-925.
Aim: to compare patient safety and analgesic efficacy of a single and high dose of
morphine given IM or IV for postop pain management.
Materials and methods: 38 patients with postop pain following hip replacement
surgery were given IM or IV morphine 10 mg at a specified pain level. The study was
randomized and double blinded. Time to onset of analgesic effect (11-point numeric
rating scale), respiratory function (paCO2, paO2, and respiratory rate), level of sedation
(5-point verbal rating scale), and hemodynamic function were recorded.
Results: In the IV group there was a slight but significant increase in paCO2 after 5,
10, and 15 min compared with the IM group (5.2 vs. 4.8, 5.4, vs. 5.0 and 5.5 vs.
5.1 kPa, respectively). The IV group had a significantly faster onset of analgesic
effect than the IM group (5 vs. 20 min). Between 5 and 25 min after morphine
administration, pain status in the IV group was significantly improved compared with
the IM group. Patients in the IV group were slightly more sedated than the IM group 5
and 10 min after morphine.
Conclusion: A 10 mg bolus dose of IV morphine given to patients with moderate
pain after surgery does not cause severe respiratory depression, but provides more
rapid and better initial analgesia than 10 mg given IM. IV morphine even at a dose as
high as 10 mg IV is well tolerated if there is a certain level of pain at its
administration. The safety of IV morphine on the general ward needs to be further
explored in adequately controlled studies.